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PAST MEDICAL HISTORY (Pediatric ≤ 18 Years-Old)

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PAST MEDICAL HISTORY (Pediatric ≤ 18 Years-Old) PAST MEDICAL HISTORY (Pediatric ≤ 18 years-old) Patient: ______________________________________________ Today’s Date: ____________________________ Date of Birth: _______________________ Age: _____ Gender (please circle): Male Female Family Doctor (Please include phone # and address):________________________________________________________ _______________________________________________________________________________________________________ Who sent you to this office?:______________________________________________________________________________ WHY ARE YOU HERE TODAY?: ______________________________________________________________________ _______________________________________________________________________________________________________ What date did your symptoms start/did the injury occur? ____________________________________________________ PAST MEDICAL HISTORY: Serious Childhood Illnesses (include hospital stays and dates):_________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Major Accidents/Injuries (include dates): ____________________________________________________________ Has the patient ever received a blood transfusion?: Yes_____ No____ Birth History: Weeks at Delivery: _____ Delivery(please circle):Vaginal delivery/C-section Reason and # of days hospitalized after birth: ________________________________________________________ Age child began walking: __________ Current Height: ____________ Current Weight: _____________ PAST SURGICAL HISTORY: (include procedure, date and surgeon)________________________________________ _______________________________________________________________________________________________________ __________________________________________________________________________________________ MEDICATIONS: (Please list name and dose)__________________________________________________________________ ___________________________________________________________________________________________ ALLERGIES:_______________________________________________________________________________ IMMUNIZATIONS: Up-to-date: _____Yes ____No FAMILY HISTORY: Father: Age_____ Mother: Age_____ Immediate family members’ disease history: (Scoliosis, childhood hip problems, diabetes, cancer, other)____________ ____________________________________________________________________________________________________________ _______________________________________________________________________________________________________ Has any family member had a major adverse reaction to anesthesia?: Yes_____ No____ SOCIAL HISTORY: School: ______________________________________________ Grade/Year:_________________ Who do you live with? ____________________________________________________________________________ Interests/Activities: _______________________________________________________________________________ Exercise/Sports/Athletic Participation: ______________________________________________________________ v. 2015_11 PLEASE CIRCLE ANY PROBLEM LISTED HERE IF YOUR CHILD HAS HAD IT AT ANY TIME: MUSCULOSKELETAL GENITOURINARY Limb or joint pain Blood in urine -which joint? _____________ Frequent/painful urination -how often? ______________ Kidney/bladder infection -when did it start? ______ Incontinence Joint swelling Difficulty urinating Back pain None of the above:_________ Please use the diagrams below to indicate the symptoms your child has had recently. Pain with activity GASTROINTESTINAL Use the key to indicate the type of symptoms. Pain at rest Ulcers/Gastritis Walking problems Decreased appetite Key: Pins and needles = 00000 Stabbing pain = ///// In toeing (toes turned in) Abdominal pain Bow legs or knock knees Black bowel movements Burning feeling = xxxxx Deep ache = zzzzz Juvenile rheumatoid arthritis Throw up blood Hepatitis None of the above:_________ ALLERGIC/IMMUNOLOGIC None of the above:_________ Allergies to medications HEMATOLOGIC/LYMPHATIC Easy bruising/bleeding Seasonal allergies Nose bleeds Food allergies None of the above:_________ Previous cancer Previous tumor (benign) CARDIOVASCULAR Bump High Blood Pressure Pain that awakens from sleep Shortness of breath None of the above:_________ Rapid/abnormal pulse NEUROLOGICAL Heart Murmur Frequent headaches Leg cramps with exercise Fainting or convulsions Poor Circulation Dizziness or tingling None of the above:_________ Diffuse muscle weakness CHEST/RESPIRATORY Tingling Chronic cough Loss of bowel/bladder control Asthma None of the above:_________ Has ever used oxygen PSYCHIATRIC Sees Pulmonary doctor Under psychiatric care Positive TB test Psychiatric hospitalization None of the above:_________ History of substance abuse EARS, NOSE, MOUTH, THROAT None of the above:_________ Neck pain/stiffness GYNECOLOGICAL Hearing problems Abnormal/irregular periods Ear infections Age periods started: _____ Sinus problems/sinusitis How many periods per year: ___ None of the above:_________ Date of last period: __________ EYES Pregnant now: Yes/No Vision changes None of the above:_________ Sensitivity to light SKIN Rash None of the above:_________ Burns ENDOCRINE None of the above:_________ Diabetes CONSTITUTIONAL Gout Parent Signature____________________ Fever/Chills Thyroid abnormality MD Reviewing Form: __________________ Night sweats Osteoporosis (weak bones) Weight loss Date: ____________ None of the above:_________ Excess weight gain or los HIV/Exposure to HIV v. 2015_11 .
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